Noninvasive positive pressure ventilation: Increasing use in acute care

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The more widespread use of NIPPV has encouraged its use in other acute situations, including during procedures such as percutaneous endoscopic gastrostomy (PEG)57,58 or bronchoscopy,59,60 for palliative use in patients listed as “do-not-intubate,”61–63 and for oxygenation before intubation.64

NIPPV during PEG tube insertion

NIPPV during PEG tube placement is particularly useful for patients with neuromuscular diseases who are at a combined risk of aspiration, poor oral intake, and respiratory failure during procedures. The experience with patients with amyotrophic lateral sclerosis58 and Duchenne muscular dystrophy57 indicates that even patients at high risk of respiratory failure during procedures can be successfully managed with NIPPV. The most recent practice parameters for patients with amyotrophic lateral sclerosis propose that patients with dysphagia may be exposed to less risk if the PEG procedure is performed when the forced vital capacity is greater than 50% of predicted.65

In randomized trials of CPAP59 or pressure-support NIPPV60 in high-risk hypoxemic patients who needed diagnostic bronchoscopy, patients in the intervention groups fared better than those who received oxygen alone, with better oxygenation during and after the procedure and a lower risk of postprocedure respiratory failure. Improved hemodynamics with a lower mean heart rate and a stable mean arterial pressure were also reported in one of those studies.60

Palliative use in ‘do-not-intubate’ patients

In patients who decline intubation, NIPPV appears to be most effective in reversing acute respiratory failure and improving mortality rates in those with COPD or with cardiogenic pulmonary edema.61,62 Controversy surrounding the use of NIPPV in “do-not-intubate” patients, particularly as a potentially uncomfortable life support technique, has been addressed by a task force of the Society of Critical Care Medicine, which recommends that it be applied only after careful discussion of goals of care and parameters of treatment with patients and their families.63

Oxygenation before intubation

In a prospective randomized study of oxygenation before rapid-sequence intubation via either a nonrebreather bag-valve mask or NIPPV, the NIPPV group had a higher oxygen saturation rate before, during, and after the intubation procedure.64

Acknowledgment: The authors wish to thank Jodith Janes of the Cleveland Clinic Alumni Library for her help with reference citations and with locating articles.

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